Services to Improve Access (SIA) Plan

Proposal to Use Kaipara Care Incorporated Services to Improve Access (SIA) Funding to Increase the Completed Immunisation rates for Age 0-5 Children

Proposal to Use Kaipara Care Incorporated Services to Improve Access (SIA) Funding to support a Pharmacy Fund at Kaipara Unichem Pharmacy

Kaipara Care Incorporated identifies 3 distinct areas of need for Services to Improve Access. These areas of need are based on the SIA methods of funding, ethnicity and deprivation. In the proposal outlined we will show where the most highly deprived clusters are within the Kaipara and how they relate to Maori. We will then propose three strategies:

• One to increase primary care free clinic capacity at two sites which are well situated and well known to Maori and people living in Quintile 5 streets.
• One to increase the range of services to Maori to encourage positive lifestyle changes for three distinct groups - older Maori, young parents, and adolescents.
• One to contribute to the increasing care costs of palliative care patients in the Kaipara (who are over-represented by high deprivation)

1. Population Patterns and Priorities in the Kaipara

KCI has 12,072 enrolled patients on its register. Sixty percent of the register has been batch geocoded during the initial CIC process by Healthpac. Further geocoding can only now occur with point of contact software being made available to the practice. At the time this proposal is made KCI has been in operation as a PHO almost 6 weeks. Despite the short timeframes, KCI can accurately identify Maori, Pacific Islands and Other ethnicities and their deprivation quintile in sufficient proportions to identify key streets and towns where significant deprived population groups occur.

Of the 12,072 enrollees 2991are NZ Maori or 25 % of all ethnicities.

2. Areas of High Deprivation in the Kaipara

As the chart above shows, most Quintile 5 people on our register live in Dargaville, followed by Te Kopuru. Smaller clusters also live in or around Ruawai, Pouto, and Kaihu.

3. Maori Distribution on the KCI Register

This table of Kaipara Towns is sorted from the Grand Total most to least of all patients whose ethnicity is described NZ Maori. Note significant numbers in each town who are un-geocoded. Those in the MISSING TOWN FIELD row are likely to have actual addresses in or around any of the other listed towns.

4. Comparison of Maori and Quintile 5 Deprivation by the Main Towns

Maori and Quintile 5 people on our register live in a number of locations within the Kaipara, but significantly large groups live in Dargaville and Te Kopuru. Of these two groups, 48% of all Maori in Te Kopuru are quintile 5, and 28% of all Maori in Dargaville are quintile 5. These concentrations are compelling reasons for KCI to review how well services have been designed to accommodate these groups of people.

5. Existing Medical/Nursing Services in the Quintile 5 Areas

Dargaville
Te Ha O Te Oranga offers free Nursing services Monday to Friday and free (or koha) GP services on three half-days per week from their premises at Dargaville Hospital. These clinics are well attended by Maori, use Te Ha nursing staff and Dargaville Medical Centre general practitioners. Cases treated at these clinics often have more complex or severe pathology than those seen at the Medical Centre, and it is well recognised that cultural and economic barriers to access have been significantly reduced as a consequence of these shared clinics. However, 3 half-day medical clinics per week do not provide the level of continuity desired by our PHO, nor do they completely meet the demand for lower cost clinics for

Te Kopuru
Dargaville Medical Centre rents clinic rooms at Te Kopuru and currently runs a 2 hour per week clinic there, in addition to a 2 hour clinic at the Te Kopuru high school. Previous years have seen this clinic operate as often as 3 half-days per week. Reduced GP availability has been the reason for the decline in frequency of clinics in recent years.

6. Existing Non-medical/Nursing Services to Maori

Maori Community Health Workers
Social Workers – 1 Alcohol & Drug Counsellor
Contracted medical clinics (3 per week)
Podiatry (subsidised clinics)
Maori Nursing & Social Rehabilitation
Young Mothers and Kaumatua/Kuia Support Group
Massage
Health Promotion & Education
Home Based Support Services

7. Key Strategies
7.1. Increasing Nursing and Medical Resource to existing Te Kopuru and Dargaville (Te Ha) Clinics (Approx 59% of SIA)

Te Kopuru and Dargaville are the best strategic locations for services to improve access. Outreach clinics already occur at Tinopai, Pouto, Ruawai.
KCI proposes an increase in GP and Nursing services in Te Kopuru and an increase in medical clinics at the Te Ha premises in Dargaville. In each case clinic demand is high, and services are well targeted to the groups of higher need (Maori and Quintile 5).

7.1.1. Te Kopuru

We will increase the frequency of clinics from 1 to 3 half-days per week, and the clinics will be staffed by an experienced community nurse from Dargaville Medical Centre. Any nursing consultations will be free. The increased availability of these clinics will allow most first assessments to be made by the nurse on duty, semi urgent cases can be dealt with within a day, and urgent cases can be referred to Dargaville Medical Centre and interim care arrangements managed by telephone. We expect a gradual increase in the use of this clinic over time, with a similar increase in previously unseen pathology. Such an increase would justify further resource of medical time.

7.1.2. Te Ha O Te Oranga O Ngati Whatua

We will increase General Practitioner time by 8 hours per week at Te Ha premises in Dargaville. This will provide a Monday to Friday free (or koha) clinic each day of the week, (an increase from 3 clinics per week). The increased medical coverage will improve options for Maori already accessing Te Ha clinics, and attract more Maori patients who wish for their routine cares to be managed at Te Ha. This new service builds on the existing collaboration between Dargaville Medical Centre (DMC) and Te Ha, in that medical resource is supplied by DMC, nursing and host facilities by Te Ha, and access to electronic medical records (DMC) is already available on-site. This means that patients exclusively registered with either provider can be seen on site with real-time medical records.

7.1.3. Proposed Resource Allocation

Total resource allocation for 12 months on these strategies is $61,520. Our timeframe for commencement is early July 2003. Contingencies are mostly around sourcing sufficient general practitioner time to cover the extra 8 clinic hours per week. Bringing locums or part-time general practitioners into the area needs to be managed in the context of providing a collaborative and supportive environment with existing GPs.

7.1.4. Possible Progress Indicators

7.1.4.1. Visit Rates
Work is in progress to establish baseline average practice visit rates for people with Te Kopuru (non RD. addresses which in most cases are quintile 5 addresses), and comparing these over time with mostly non quintile 5 towns. Increased visit rates could be an expected with a 3 day per week clinic at Te Kopuru. We predict lower average visit rates for Quintile 5 and Maori patients than for non-Maori, and lower quintile groups.

7.1.4.2. Complexity
Increased need for medical clinics should be a by-product of this intervention. Free nurse access on a daily basis should find more previously unknown cases of greater complexity over time. It may take analysis of single diseases such as diabetes (annual review data) or asthma to measure this expected trend.

7.2. Increasing the range of “Wrap Around” Services to Maori at Te Ha O Te Oranga O Ngati Whatua (Approx 34% of SIA)

Changing the way Maori feel about using their health facilities at times other than when they are very ill is one of the reasons behind three proposed strategies outlined below. The groups identified are

7.2.1. Proposal for improved access to services:
The PHO requires Primary Health Providers and other services to work in a collaborative and integrated way. The SIA funding in our view encourages this and we know that this funding is also to be focussed towards health improvement for Maori. Our proposal therefore focuses on how Maori can best benefit directly from the services available with minimal or no cost to them.
Buy in, leadership, collaboration and integration with all services identified is essential thus highlighting the need for a coordinator of the programmes outlined below.. Maori under this funding have the opportunity to access this programme that they can relate to and express their need for their well-being and health maintenance.

Appropriate wrap around health services to the group when they meet would improve access to a greater number of identified health services. Expanding this concept to other areas such Te Kopuru as well as Dargaville would also improve access to the wider Maori community. Accessibility, affordability, accountability and appropriateness would be achieved, as it would have a direct benefit for Maori.

Expanded wrap around services to this group could include:
• Podiatrist
• Budgeting skills
• Dietician
• Physician
• Social services
• GP service, Green prescription
• Maori rongo (alternative medicine as appropriate)
• Smoking cessation programme
• WINZ awareness programme
• Housing support programme
• Transport service
• Stroke support service
• Optometrist
• Hearing aid service
Obviously not all of these services would be required weekly. Decisions on frequency of availability would occur through collaboration with services by the coordinator.
This programme with the proposed appropriate wrap around services would not only
meet the SIA funding requirement but would enable the precipitating health determinants of:
• Lifestyle(smoking, nutrition, exercise)
• Poverty (low socio- economic status)
• Housing (overcrowding, sub-standard)
to be changed by carefully selected interventions over time.

7.2.2. 7.2.1.Kori Kori a iwi (exercise) and eating Programme for Kuia/Kaumatua (older population)
7.2.2.1. Introduction:
Through discussions/consultations/hui with the Kaipara Maori community the above programme was identified as a health need. The Disease State Management Nurse (DSM) within the mobile nursing service of Te Ha 0 Te Oranga 0 Ngati Whatua developed and implemented this programme additional to our core contract work.
Consultation with Kuia and Kaumatua resulted in Te Ha being identified as an appropriate service and venue to come together and participate in a series of exercises for them as well as those who have disabilities and are confined to wheelchairs. The use of Maori music, poi and rako to do the exercises is significant to the well-being of the group and therefore meets a health need. A sensible eating plan is shared to encourage weight control as they exercise.
This programme is particularly good for the rehabilitation of the major diseases amongst Maori like Diabetes, respiratory and cardio vascular conditions.
The opportunity to access SIA (services to improve access) funding for Maori, has caused us to look closely at this programme and explore ways to achieve optimum health gains. We believe that appropriate wrap around health and other services to the group when they meet would do this.
In this report I will explain the programme, identify the issues and discuss the proposal of wrap around health services to improve access for Maori.

7.2.2.2. Programme:
The group who meet weekly from 10 - 12.00 at Te Ha in Dargaville are currently women. The programme is facilitated by a nurse and community health worker. The exercises involve the coordinated movement of limbs and body but also stimulates the mind to actively work on limb movement. It is performed to music which Maori are attuned to and therefore a greater level of coordination is achieved through their musical tendencies , as well. Obviously the use of poi and rako to do the exercises encourages participation. As mentioned addressing the major diseases affecting Maori is the aim of this programme.
A sensible eating programme is included in this programme whereby the facilitators promote healthy eating and each member of the group share their notes on how they have ; managed for the week. Weight progress is recorded and goals are set for the next week.
A healthy lunch is provided at the conclusion of the programme.
The programme is run by the goodwill of our mobile nursing team who support/facilitate the programme and provide health education sessions as requested or cover health topics from the national health calendar.
Transport to attend this programme has been an issue for some so we have provided this knowing that it is an additional cost to us.

7.2.2.3. Issues
Assessment by the DSM nurse concludes that health and other services could have been available on the day to meet other needs of the group (see list below).
Lack of transport and telecommunication is a big issue for whanau who are referred to other services on different days due to unavailability of the service at the time. Maori accessing this programme do so because it is a safe place for them and it meets their cultural need. To be able to access health and other services while there would certainly enhance the programme.

7.2.3. Parent/Whanau group Programme
7.2.3.1. Introduction:
Through discussions/consultations/hui with the Kaipara Maori community the above programme was identified as a health need. The mobile nursing service of Te Ha 0 Te Oranga 0 Ngati Whatua developed and implemented this programme additional to our core contract work.
Maori with young families identified Te Ha as an appropriate service and venue to come together and participate in cultural activities such as weaving, waiata (songs) crafts, cultural identity and te reo (language). It has become obvious over time that the learning and increased self-esteem demonstrates an aspect of what makes a "healthy Maori" and therefore meets a health need.

7.2.3.2. Programme:
The group who meet weekly from 10am - 2.30pm at Te Ha in Dargaville and are mostly mothers and grandmothers. They are supported by volunteer kaumatua and kuia who teach the cultural activities. Their pre-school children/grandchildren are often with them and they too enjoy the activities. The programme is run by the goodwill of our mobile nursing team who support/facilitate the programme and provide health education sessions as requested or cover health topics from the national health calendar.
The group named "Ka Pinea Kia Mataara" have been able to access our service for well child checks, immunisations and the ear caravan when they meet. Transport to attend this programme has been an issue for some so we have provided this knowing that it is an additional cost to us.

7.2.3.3. Issues
Our staff have identified through assessment, other health needs from other services that could have been available on the day (see list below). Lack of transport and telecommunication is a big issue for whanau who are referred to other services on different days due to unavailability of the service at the time. Maori accessing this programme do so because it is a safe place for them and it meets their cultural need. To be able to access health and other services while there would certainly enhance the programme.

7.2.4. Youth/Adolescent Programme
7.2.4.1. Introduction:
Te Ha does not have any dedicated programmes as such for for this grouping, however we do have various activities where adolescents are involved in tramping, canoeing, kori kori a iwi, kapa haka.
We currently have a male health promotion community worker who is developing
programmes to work with adolescents in schools such as Dargaville intermediate and Kaihu.

7.2.4.2. He is also working on a sports programme at the request of a local rugby club. The opportunity to access SIA (services to improve access) funding for Maori, has caused us to look closely at this large population base and explore ways to achieve optimum health gains for adolescents. We believe that appropriate wrap around health and other services to the group when they meet would do this.

Conclusion
Improving access to health services for Maori is about making sure that they have the opportunity to do so without additional physical or financial duress. Well coordinated wrap around health and other services, alongside our existing programme is a sensible approach that benefits Maori directly, and ensures the proactive interaction of the services involved.

7.2.5. Proposed budget for the 3 “Wrap-Around” Strategies

Te Ha O Te Oranga is committed to implementing the three strategies outlined above. The major resource requirement will be appointment of a Coordinator, although Te Ha will manage these services amongst their wider team. This position will cost approximately $70,000.

KCI will commit half of this amount or $35,000

7.2.6. Possible Progress Indicators

• Attendances for each programme
• Evaluation Hui
• Attendees also using Te Ha medical and Nursing Services

7.2.7. Timeframe for Service Delivery

Recruitment of a suitable Programme Coordinator is the major consideration in these strategies being fully implemented, however, KCI understands that this is already progressing well, such is the commitment of Te Ha already. Should recruitment delays occur, Te Ha undertakes to implement the programme on a limited basis within existing staffing and time constraints.

7.3. Funding Part of a Shortfall in Kaipara Palliative Care Services

Kaipara Palliative Care is a well-performing Society with a staff of approx 1.5 FTE which faces an increase in service demands (intervention patterns show much earlier referrals. KPC is involved with patients earlier in their illnesses than ever - because of its higher community profile. This is desirable but means staff time & resources are tied up for longer.
KPC is also seeing terminally ill patients younger. Younger terminally ill patients require more resources, family members must continue to work, more nursing time is needed.
Each year KPC saves the NDHB from making extra district nursing visits & travel costs; reduces their referrals for mental health referrals and reduces the number of after hours hospital calls. By assisting about 38% of its patients to die at home, KPC saves the NDHB $113,000 in the cost of hospital bed-stays. In addition through its unpaid volunteers, its bereavement support meetings, and aromatherapy visits a further $15,000 (conservative estimate) is saved.

A highly successful fundraising committee and staff last year purchased $22,000 worth of electrically raised beds, wheelchairs and morphine pumps and the building of an ensuite within Dargaville hospital for palliative care patients.

The current Palliative Care Contract with Northland District Health Board is $54,000 per annum which will be rolled over. There is no immediate prospect that this amount will be increased. The total running cost for KPC per annum is $115,000. The projected fundraising and other income (interest etc.) will meet only $88,000 (incl contract) leaving a deficit of $27,000.

7.3.1. Why Palliative Care Qualifies For SIA Funding Consideration

62% or (28) of their 45 patients in the last year have addresses in Quintile 5 streets - 19 in
Dargaville, 3 in Kaihu, and 6 in Te Kopuru. This high loading of deprivation is unexpected and deserves further study in its own right.

22% of Palliative Care patients receiving care in the last year are Maori. Good linkages and confidence in the service with Te Ha O Te Oranga staff have assisted a near representative proportion of Maori to be accessing this service.

7.3.2. Level of Funding Proposed

* only if the uncommitted SIA income supports it.

7.4. Appendix 1

Summary of SIA Spend

SIA Projects

* $5000 allocated is contingent upon total yearly SIA funding yielding $103620 or more.

Proposal to Use Kaipara Care Incorporated Services to Improve Access (SIA) Funding to Increase the Completed Immunisation rates
for Age 0-5 Children

This proposal sets out to put extra resource into completing overdue immunisations for the pre-school children in the Kaipara. Some towns such as Pouto, Kaihu, Te Kopuru and Dargaville have previously been identified as being high in deprivation (Quintile 5) and having high proportions of Maori families.

Our previous efforts to increase the levels overall in these particular immunisations have been successful to a point over the past years with collaborative working relationships between KCI, Te Ha o Te Oranga (Maori Mobile Nursing Service), Plunket, the Regional Immunisation Coordinator and Dargaville Medical Centre. But we have now identified that to meet nationally set targets in immunisation a more targeted “outreach” strategy must be employed, offering home-based immunisations to families who are least likely to seek this service for themselves. The graph below for 0-2 Years shows an actual decline in our joint performance since June 01 for this age-group and this is the most compelling reason for this proposal.

The graph below shows our performance over the various age-group vaccinations. Our providers have long realised that to make a significant difference to the “harder to get” immunisations (the last 30%), resource must go into training and certifying more Independent Vaccinators, and ensuring vaccinations can be given at home.

Age Group Targets

Currently the number of overdue or incomplete immunisations for the following age groups is as follows:

To catch up 249 children’s vaccinations involves a range of approaches. Not all require home visiting, and those who do may need up to 4 visits. Our calculations must take into consideration Nurses’ travel time, vaccination and post-vaccination (20min) time. Home visits must be done in pairs for patient safety reasons. Some destinations are as far as 140 km, 59% are within 4km and 41% average 53km.

Immunisation Infrastructure Costs

To deliver this kind of service 4 more nurses require training as Independent Vaccinators and we have allowed for one more nurse to be trained as a Vaccinator. This infrastructure development will also be important when the new “B” strain Meningitis vaccine becomes available in 2004. The table below sets out the costs to upgrade four current vaccinators to become Independent Vaccinators and one nurse to become a Vaccinator.

This proposal is drafted on behalf of the KCI Immunisation Team. The team recognises that there are limited funds available to KCI for projects of this nature, and that equally worthwhile projects are competing for these funds. We therefore offer the following compromises in seeking this resource:

The revised costs for option One have come about from further discussions with provider stakeholders who note that the Nurses’ Rural Consortium have traditionally contributed to vaccinator training, and that providers themselves should also make a contribution. Other opportunities for combined Te Ha/DMC approaches such as one providing the independent vaccinator, the other the enrolled/CPR nurse in a shared arrangement would reduce duplication and have other benefits.

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Proposal to Use Kaipara Care Incorporated
Services to Improve Access (SIA) Funding to support a Pharmacy Fund at Kaipara Unichem Pharmacy

That a fund of $2000.00 be placed with Unichem Pharmacy to be used at the discretion of GP’s, for those who suffer financial hardship in paying for their scripts. The fund will be administered and reported on by the Pharmacy.

This was once funded by the Rotary club, who are now unable to contribute.